“.. I think this is maybe our Achilles Heel....” Exploring GPs' responses to young people presenting

73 Pages·2013·1.15 MB·English

BMJ Open

“.. I think this is maybe our Achilles Heel....” Exploring GPs’
responses to young people presenting with emotional
distress in general practice. A qualitative study.

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Journal: BMJ Open
Manouscript ID: bmjopen-2013-002927
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Article Type: Research

Date Submitted by the Author: 21-Mar-2013
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Complete List of Authors: Roberts, Jane; University of Sunderland, Pharmacy, Health & Well-being
Cerosland, Ann; University of Sunderland, Pharmacy, Health & Well-being
Fulton, John; University of Sunderland, Pharmacy, Health & Well-being
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<b>Primary Subject
General rpractice / Family practice
Heading</b>:

Secondary Subject Heading: Mental healthr, Medical education and training, Qualitative research
PRIMARY CARE,e MENTAL HEALTH, Child & adolescent psychiatry <
Keywords:
PSYCHIATRY
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“.. I think this is maybe our Achilles Heel....” Exploring GPs’ responses to young people presenting
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7 with emotional distress in general practice. A qualitative study.
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12 Jane H Roberts , Ann Crosland, John Fulton
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Department of Pharmacy, Health & Well-being, Faculty of Applied Sciences, The Science Complex,
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16 Wharncliffe St, Sunderland, SR1 3SD.
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Jane H Roberts, Clinical Senior Lecturer, University of Sunderland,
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Ann Crosland, Professor of Nursing , University of Sunderland,
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John Fulton, Principal Lecturer, University of Sunderland,
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Correspondence to Jane H Roberts r
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[email protected] r
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5 “.. I think this is maybe our Achilles Heel....” Exploring GPs’ responses to young
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people presenting with emotional distress in general practice. A qualitative study.
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11 Article summary
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13 Article Focus:
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1. an exploratory study
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16 2. to examine GPs’ views and experiences of consulting with young people
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18 3. to understand GPs perspectives
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20 Key Messages
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22 1. GPs collectively describe anxiety and uncertainty about their clinical
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practice when consuelting with young people in distress, independently of age and
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gender
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2. Anxiety relates to professional performance; interacting with young people
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27 and the complex nature of presentations of emotional distress in primary care

28 3. Unless anxiety and uncertainty are addressed GPs will continue to miss
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29 opportunities to address early emotional difficulties and young people’s mental
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health needs in primary care will ceontinue to be poorly met
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32 Strengths and Limitations v
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1. Qualitative research in under -examined areas offers new insights and
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explores why behaviours might arise
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2. The data contributes to theory building and offers theoretical
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38 generalizability

39 3. Theoretical sampling led to only white British born GPs participating so
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3 “.. I think this is maybe our Achilles Heel....” Exploring GPs’ responses to young
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people presenting with emotional distress in general practice. A qualitative study.
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Main text
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12 Introduction
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14 Emotional distress in young people is common. It may indicate an associated mental
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16 heath probFlem, with at least 10% of 10-15 year olds affected 1 and 17 % of 16-19
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year olds 2 (baosed on household surveys). Proxy markers of distress, such as
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19 reported incidencres of self-harm derived from community based studies, show 10%

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21 of adolescents report having self-harmed. 3
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Data from populations ofe young people who consult their GP reveal higher rates of
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25 psychological distress, of thee order of 20-30%. 4 5 GPs identify serious mental illness
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but often fail to detect less severre manifestations 6 and appear reluctant to discuss
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28 emotional issues7; unless offered cures by the young person in the consultation 8 or if
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30 other factors are present such as a previous history of a suicide attempt or a pattern
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of frequent consulting 9. Young people’s presentations in primary care are often
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complex and present with behavioural, psychosocial, academic and familial
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35 problems which can be problematic to untanglee. They may suggest underlying co-
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37 morbid mental health problems. It has been reported that often the ‘most important
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38 features in terms of assessment may be concealed or hidden’.10.
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41 A key concern is the difficulty of distinguishing between ‘moodiness’ or a persisting
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emotional disorder and GPs have expressed a worry at ‘over-medicalising young
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44 people’s lives’.11 Illiffe & colleagues found that GPs were uncomfortable about
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46 making a diagnosis of depression in young people (the most common, but often
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coexisting, mental health problem in adolescence ).
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50 This sits in contrast to GPs’ increasing involvement of common mental health
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problems in older patients 12 13and also to a broadening of the frames of reference
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by which emotional distress in adults is regarded. Although a biomedical perspective
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55 dominates, supported by an array of NICE clinical guidelines, Dowrick 14and Reeve
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15 have offered alternative frameworks and refer to the insights derived from the
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3 wisdom traditions. Historically, GPs have been found to be dismissive of their role in
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addressing social issues in adult mental ill-health 16 although this position is shifting
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with greater awareness of the lay perspective, which typically favours the causes of
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8 mental ill-health ( notably depression) as being social in origin 17.
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Despite the challenge of responding to emotional distress in adolescence and the
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12 patchy, often inadequate provision of secondary care services 18 19a series of policy
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14 directives have emphasised the role of GPs and other front-line services, in the
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promotionF of psychological well-being and the early indication of difficulties. 20 21 22
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17 Practitioners are expected to have ‘sufficient knowledge, training and support ‘in this
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19 area including cormpetence in ‘active listening’ and conversational technique’ 23.

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There is a growing body of evidence examining young people’s experiences of
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23 talking to GPs about emotional problems. They reveal a mixed picture including a
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reluctance to disclose 24, a fear of being judged or offered medication 25. Much less
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is known about GP perspectivesr. This paper presents a qualitative, exploratory study
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presenting with emotional distress.
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32 Method v
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Study Design
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37 The study took place in the North East of England in 18 general practices based in
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urban, rural and semi-rural communities serving predominantly socio-economically
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disadvantaged patients. The qualitative study comprisedo of in depth individual
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42 interviews with GPs recruited using theoretical sampling. Asn early theoretical ideas
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emerged successive GPs were recruited on the basis of their capacity to contribute
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to the development or abandonment of initial theoretical constructs.
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48 Data were collected between January 2010 to May 2011
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Participants
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53 GPs with less than four years clinical experience were excluded. The initial recruits
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were selected on the basis of their relevant experience and their ability to generate
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56 early data which would scope the terrain of the area under enquiry.
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3 GPs were approached by telephone and email contact and sent information sheets.
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A follow-up contact established their verbal consent to meet at a location of their
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choice.
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9 Data collection and analysis
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The audio-taped semi-structured interviews were transcribed verbatim with consent.
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13 An initial topic guide was used with the first tranche of participants based on the
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extant literature and developed through discussion. The topic guide was then revised
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16 on the basis of ideas arising from the early interviews, and the iterative analysis
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18 which began as soon as the first interview was undertaken. The interview guides
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explored doctors’ ex periences of consulting with young people in general and those
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presenting with psychological or mental health problems, GPs’ understanding of
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23 depression and anxiety in adolescence, of how emotional distress presents in the
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surgery and the role of the GP in promoting emotional well-being in young people
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(See appendix 1). The guide wars refined to include questions about how structural
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28 changes impacted on, and consultation style shaped, practice.
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The interviews lasted between 50 to 7e5 minutes. Field notes and theoretical memos
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32 were kept throughout the period of data cvollection and analysis.
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The transcripts were coded and analysed using the grounded theory method
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36 described by Strauss and Glaser 26 and revised by Charmaz .27 The constant
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38 comparative method of analysis is core to the process and informs the theoretical

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sampling of recruits. Situational maps, both ‘messy’ and ‘ordered’, were constructed
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The data presented here was produced after the first level of analysis was completed
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during which the open codes were developed by JR and subject to further
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47 examination by AC (primary care academic) and JF(sociologist)
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Results
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52 Nineteen GPs participated, 10 women. (Table1). The early iterative analysis of the
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data found a dominant narrative of anxiety and uncertainty about practice under-
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pinning the majority of the research interviews. This pervasive and disabling
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3 emotional response to encounters with emotionally distressed young people
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appeared to coalesce around three domains.
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7 These can be viewed as anxiety and uncertainty experienced by GPs in response to:
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1) professional performance; in the consultation, at an external level, across
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disciplinary boundaries;
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2) interacting with young people; and
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19 Anxiety related tro professional performance: In the consultation

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21 A prevailing finding was the sense of professional impotence which was associated
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23 with seeing or suspecting emotional distress in this age group. It was acknowledged
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that feeling unsure of practice led to a sense of disempowerment through not
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26 knowing what to do; in contrast to working with older patients where the options
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28 appear more clearly defined. The data collected suggested that not being able to
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formulate the initial presentation by a young person into a definable ‘disorder’
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This was amplified by the lack of exposure to adolescent mental health in
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undergraduate medical education which was unanimously shared by all participants.
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37 Where the topic had been included in the curriculum, it was often restricted to severe
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mental disorder such as adolescents hospitalized with anorexia nervosa.
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41 Anxiety related to professional performance: at an external level
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The lack of benchmarks meant assessing one’s performance in relation to peers was
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45 problematic since no ‘gold standard’ existed. The only NICE guidyeline which was
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47 referenced (concerning the management of depression in under 18 year olds) was
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regarded as having hampered GPs from becoming involved in the management of
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50 adolescent depression and supporting a view that there was little to be offered in
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52 primary care.
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Varying arrangements within practices governing access to appointments and the
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56 ease, or not, of maintaining continuity of care were seen to contribute to professional
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3 anxiety by impeding attentive ‘watchful waiting’ and some GPs described attempts to
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circumvent inflexible appointment systems in order to be more available to patients.
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7 A lack of professional supervision was identified by a small number of more
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9 experienced GPs involved with Postgraduate Training and provision of mental
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health services at a regional level, and contrasted to systems for other professionals
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12 working with emotionally distressed patients. Leaving GPs to rely on their own
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14 personal resources, on informal collegiate support or ad hoc relationships with
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colleaguesF in secondary care resulted in a fragile structure which could amplify
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Anxiety related to professional performance: across disciplinary boundaries
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reporting long delays and frequent rejection of referrals, and a lack of clarity about
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25 how the services were strucetured and governed. GP experiences and degrees of
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29 associated with higher levels of profressional anxiety. More constructive cross-
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disciplinary relationships were describeed with CAMHS workers offering clinical
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32 updates meetings and were consultants wvere accessible by telephone.
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Anxiety related to interacting with young people
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37 The early finding of anxiety and uncertainty in this area was under-pinned by the
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difficulties GPs talked about experiencing when communicating with young people.
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Neither the age nor the gender of the GP appeared to faocilitate communication.
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42 Female patients were generally considered to be easier to tnalk with whilst young men
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were seen to be more challenging because of their perceived reluctance to seek help
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and their tendency to present late.
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48 Communication difficulties included establishing a rapport, finding the right words
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and tone to use and dealing with silence. An inability to read the non-verbal signs,
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accompanying parent or closing down the consultation.
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3 Young people were seen as a highly heterogeneous group who showed variability
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from one presentation to the next, and also across lines of age and gender. Knowing
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what was ‘normal’ for an individual, particularly if it was presented as a principal
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8 reason for consulting with the GP, was perceived as problematic and anxiety
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provoking, both for the young person and for the GP.
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12 Anxiety associated with the complexity of presentations of adolescent
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16 GPs’ accounts of their experiences described a terrain beset with pitfalls, associated
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was a sense of unp redictability and volatility to presentations which left GPs
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uncertain about how much input to offer at the initial consultation. This was in
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23 contrast to the rare but grave consequences which might arise when a young person
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seriously attempted or completed suicide; to which many GPs referred.
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29 restricted to the clinical area of youtrh mental health, the early analysis showed a
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distinct narrative emerging in which adeolescent mental health was seen as more
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32 notably anxiety provoking because of its mvore nebulous presentation and multiple
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confounding factors, largely pertaining to the social environment. The account given
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in the consulting room was described as the ‘iceberg’ indicating that often much is
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young person’s distress is to be addressed.
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43 GPs make sense of adolescent emotional distress, but similar rlesponses surround
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management options. Few GPs expressed any degree of confidence about how they
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46 would tackle individual presentations. A small number of those with additional roles
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48 in mental health or working with patients with substance abuse problems spoke of a
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more systematic approach but even established GPs with personal experience of
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51 working in ‘a teen drop-in clinic’ or with drug dependent patients were uncertain of
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clarity about what GPs might reasonably do, if supported by adequate professional
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3 Discussion
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6 Summary
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Anxiety and uncertainty associated with adolescent emotional distress emerged from
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10 all GP participant accounts and from the early iterative analysis of the data. Anxiety
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how they might best respond in the absence of few clinical guidelines and limited
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15 options to involve other health and social care professionals. Unease when
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17 communicating with young people and of interpreting their accounts of distress
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19 inhibited GPs andr was compounded by the complexity of presentations which

20 ranged from familial discord to school refusal to offending behaviour. The
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22 heterogeneity of adolpescent behaviour taxed GPs as did the unpredictability of the
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unfolding clinical presenteation which could settle spontaneously or develop into a
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25 serious mental health disordeer.
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28 Whilst there was a spectrum of levels of anxiety experienced by GPs, there was a
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prevailing universality about the experience. How GPs responded and managed the
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perceived threat to professional competence and confidence was interrogated in the
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36 Strengths and limitations
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The management of adolescent mental health problems remains an under-
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investigated area of clinical practice. Previous studies haove often been conducted by
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42 psychiatrists and whilst plurality of perspectives is importantn, unless more is known
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and understood about how GPs perceive the area many assumptions will go
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unchallenged. Using grounded theory, augmented by situational analysis, permits a
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47 rich exploration of the territory and facilities theory building.
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50 Theoretical sampling supports theory development whilst not purporting to provide
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universal generalizability. After 19 in-depth interviews, buttressed by situational
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53 analysis, no new themes emerged and theoretical saturation was reached. All of the
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55 respondents were white British and whilst they were recruited on the basis of their
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contribution to the study, it must be acknowledged that the absence of including the
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